Clinical Documentation Specialist

This is a fully remote position, open to applicants in Iowa.

📋 Description

• Leverage clinical and coding knowledge to guide initiatives aimed at maintaining the integrity of clinical documentation as a reviewer, educator, and consultant.

• Enhance the quality, completeness, and accuracy of medical record documentation through comprehensive record evaluations.

• Ensure that clinical documentation accurately represents the severity of illness, risk of mortality, quality indicators, and the level of services rendered.

• Engage in communication and education with physicians and healthcare team members regarding clinical documentation practices.

• Oversee provider engagement.

• Perform concurrent reviews of selected patient health records to assess legibility, clarity, completeness, consistency, and precision.

• Develop compliant clarifications and queries in accordance with Trinity Health's documentation integrity protocols.

• Embody the Trinity Mission, Vision, and Values in actions, practices, standards, policies, procedures, and decision-making.

⛳️ Requirements

• Associate/Diploma Degree in Health Information Technology (HIT) or an advanced degree in nursing (NP, APN) or as a Physician Assistant.

• In the absence of a college degree, three (3) years of experience as an inpatient coder or documentation specialist is required.

• Preferred certifications include: RN, RHIA, RHIT, CCS, CCDS, or CDIP.

• Experience in critical care, medical, or surgical inpatient nursing as an RN, PA, NP, APN, or inpatient coder is preferred.

• Exceptional communication, interpersonal, collaboration, and relationship-building skills are necessary.

• Strong critical thinking abilities and the capacity to integrate knowledge effectively.

• Skills in prioritization and organization are required.

• Proven ability to utilize standardized desktop and Windows-based computing systems.

• Data entry and typing skills should be at a minimum of 30 words per minute.

🏝️ Benefits

• Full-time remote position.

• Day shift.

• Equal Opportunity Employer.